Healthcare Provider Details

I. General information

NPI: 1326594300
Provider Name (Legal Business Name): DAVID E KOCH APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2016
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
LEBANON NH
03756-1000
US

IV. Provider business mailing address

1 MEDICAL CENTER DR
LEBANON NH
03756-1000
US

V. Phone/Fax

Practice location:
  • Phone: 603-650-8022
  • Fax:
Mailing address:
  • Phone: 603-650-8022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number065410-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: